Management of immune-mediated uveitis

Immune-mediated uveitis is a collective term referring to a group of potentially blinding intraocular inflammations which may coexist with systemic inflammatory diseases. T lymphocytes appear to play an important pathogenic role in uveitis, and these cells are therefore the logical target of drug therapy. Corticosteroids act nonspecifically, but are highly effective in controlling the inflammation rapidly. They are administered locally when disease is confined to the anterior portion of the eye. However, posterior eye involvement often requires systemic corticosteroid therapy, carrying a high risk of serious adverse effects when used for extended periods. In this situation, steroid-sparing agents are used. Few relevant randomised, controlled clinical trials have been performed, and the choice of systemic immunosuppressive regimen is usually guided by individual patient characteristics, cost, drug availability and physician preference. Patients should actively participate in therapeutic decision-making. Our first choice for steroid-sparing medication is often methotrexate, an antimetabolite which carries a low risk of adverse reactions when appropriately prescribed and monitored, is relatively inexpensive, and has once-weekly ease of use. For more severe uveitis, we may combine the immunomodulating agent cyclosporin with methotrexate and a corticosteroidl Azathioprine and cyclophosphamide are other treatment options. Steroid-sparing drugs also have significant potential for causing adverse effects, albeit less frequently than corticosteroids. Future therapies aim to reduce this problem by increasing the specificity of the therapeutic action.